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New Grad in Ortho -- Dictating

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Hi All,


I searched around this forum and wasn't able to find anything but I hope I'm not asking a repetitive question. I'm a new grad and just started my first job in ortho (today actually was my first day). One of the things I'm very nervous about is dictating. I have some degree of ADHD (diganosed and I am taking medicine for it) so I have a hard time sometimes with organizing my thoughts in my head. I'm much better at writing things out first but I know that isn't an efficient use of my time.


I was wondering if anyone had any experience with dictating and if they had a good template to follow or able to point me in the right direction. I just started shadowing (and will be shadowing for a while) but apparently even when shadowing some of the providers will have me dictate a few notes. I am just looking for any advice/reassurance I guess!

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After having done this for a long time, some stuff becomes habit and I use the same order every time, every clinic note.


However, I have a lot to remember - so cue notes help a lot.


I made a word document and printed it out. I take a page into each room and make written notes - that is how my brain works. I then use the note to dictate.


My Family Practice note looks like:












Meds: - our computer does this - I verify it and it is wrong a lot


All: I ask EVERY time


ROS: The computer has a check box - meh, not so awesome. I have a brief list of systems under the ROS and put a null sign if nothing or jot notes.


I write my plan sideways in the corner - weird habit. I make quick physical exam comments all over and only I know how to interpret them - freaks my staff out. 


I often have 20 charts to do - 10 or 11 at lunch and that many at end of day - rarely time to dictate during while I see patients. I remember writing things and it jogs my memory. My notes are thorough and paint a picture for anyone else who reads them. 


Set up your habit, perfect it and stick with it. Doing it the same time - every time - whether a complete physical, a sick visit or an ortho visit - you are less likely to forget things.


Get to know your transcriptionist - if it is a human..... My old human transcriptionist would come to me and say "you were really tired and this sounded like crap - so I fixed your grammar." I loved her. Now I talk to Dragon and cuss at it when it can't figure out words or refuses to learn. If I hand typed everything, I would be a carpal tunnel and DeQuervain's patient.


Speak slowly and it will get better, faster and more routine for your brain. 


I shred my handwritten when done.


Works for me. You might try it.


My very old 2 cents

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Memorization, notes and charting/dictation can be an overwhelming process in every area of healthcare.  Having experience as an RN, I can tell you that creating a template to organize thoughts and jot down notes will be the key to your success!  After you get more comfortable and proficient, you will have less to write out and just a few key words will cue you in on what needs to be dictated.  Also, it might be worth asking the PAs and/or MDs you are working with/shadowing what little tips and tricks they have.  (keep in mind I am at the beginning of my PA school journey, so I do not speak from PA experience... but do know a thing or two about nursey stuff).

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  • 2 weeks later...

Dictating is daunting at first. I used my Maxwell guide and would write out a complete note just to read it into the phone. Just the dictation part of a consult would take me 20-25 minutes. But having a system, or template, got me used to it after a few months. Now I can dictate using Bluetooth while driving from the hospital to the office.


For me, having a template of a normal person with noninjury is a good place to start, then I just ammend according to the injury and presentation. Again, Maxwell is really handy for this.


Take your time, go slow, pause the dictation if you have you have to think or need to pull up a note for reference. Oh that reminds me, sometimes I would pull up a completely different patient just to see someone else's dictation to use as a cheat sheet.

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This made me think of a question, even though I'm still pre-PA. What happens if you see at pt at, say 9am, and when you go to dictate at noon you can't remember something. For instance, they had numbness in one finger but you can't remember which. Do you have the patient come back in, or is this just unheard of?

Never lie. Record what you do remember, record what you THINK you remember as things you think you remember.

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